GW1--02699_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells 1
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES I.
g y FROM TO DESCRIPTION I I
Well Contractor Name '109 ft. 111 ft. I 3 gpm
4070-A 113 ft. 117 u. I , 4 gpm _
NC Well Contractor Certification Number 15.OUTERCASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 44 ft. 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
202318W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft.
ft in. .
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tL it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft.. 20 ft• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer PROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 13 ft Wet Red Clay
9/9/23 13 ft, 19 ft. Brown Dirt
4.Date Well(s)Completed: Weil BM ,
19 ft. 245 ft. Slate
5a.Well Location: ft. ft. ' .
Brenda Vuncannon ft., ft.
Seams:51',93', 109'=3g, 113'=4g
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Dennis Rd, Troy 27371 (Hidden Lake, Lt 6) rt. ft
Physical Address,City,and Zip 21.REMARKS
Montgomery 6589-15-54-6687 t is `-`ii....•t le a- �-
County Parcel identification No.(PIN) MAY CI d 2024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) lT�i+'ir_': ,.-, :i)e,,.--,...':3!,),�1Q
N W Z)(,t✓ � t '10/1/23
Signature o edified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fell out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-ivatersupply wells OM-Elvish the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS 1,
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form.within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use" " 1617 Mail Service Center,;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In'addition to sending the form to the address in
Rota 24a above, also submit a copy of-this form within 30 days of completion of well
12.Well construction method: ry - - - - construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • - 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 7 Method of test: Air Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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